Atrial Fibrillation Ablation with a Novel Fully 3D-Mapping-Integrated Multi-Electrode Radiofrequency Balloon Catheter

Pulmonary vein isolation (PVI), as the cornerstone of atrial fibrillation (AF) ablation, has emerged a widely used therapy for patients suffering from AF. To improve PVI efficiency, single-shot catheters (SSCs) have been developed. Regrettably, SSCs are not integrated into 3D-mapping technology. In that regard, a novel radiofrequency balloon catheter (RFBC, Heliostar, Biosense Webster) with full integration into 3D-mapping technology has been developed. The aim of this study was to assess operative and follow-up outcomes of the RFBC in AF patients. In this monocentric prospective registry, patients with a first-time PVI using the RFBC were included. Follow-up visits were scheduled 3, 6, 12 and 24 months after ablation and in case of symptoms. A total of 171 patients (36.8% female) were included, with a mean age of 68.5 ± 10.2 years. Among them, 63 patients (36.8%) presented with persistent AF. Notably, no major periprocedural complications were observed. The mean follow-up period was 287 ± 157 days. In the Kaplan-Meier analysis, the estimated recurrence-free survival after 12 months was 81.8%. Based on our data, PVI with the fully 3D-mapping-integrated RFBC seems to be safe and effective and to have a favorable 12-month outcome in patients with paroxysmal and persistent AF.

Biotechnological and socio-environmental potential of Campomanesia adamantium (Myrtaceae): an interdisciplinary review

Guavira (Campomanesia adamantium, Myrtaceae) is a native fruit from the Brazilian Cerrado savanna and is socio-economically important for the indigenous and traditional people living in the Central-West. This is a bibliographic review of the biological properties of guavira and its derivatives, and, after discussing experimental studies, an interdisciplinary approach is conducted highlighting the im-portance of Agroforestry Systems as an ecological restoration tool to leverage the production chain of guavira while providing ecosystem services. Many research groups studied effects of polyphenols and other bioactive compounds and biological properties of this fruit and other plant parts such as antibiotic, antioxidant, anti-inflammatory, anti-hyperlipidemic, anti-diarrheic and antitumoral activities, cardiovascular and hepatic protection and action against neuropathic pain. Besides, guavira by-products benefit poultry intestinal health, similarly to antibiotics added to their feed. Furthermore, several biotechnological products were found, like pulp flour, seasoning from the peel, sunscreen, and seed oil similar to olive oil with pharmaceutical and industrial potential. We conclude by emphasizing the importance of guavira for restoration and preservation of the threatened Brazilian Cerrado, and for the socio-environmental development of family agriculture. The same approach and study are welcome and necessary in other regions and domains worldwide having their native flora as means for a restorative end.

Machine learning-based prediction of in-hospital death for patients with takotsubo syndrome: The InterTAK-ML model

AIMS

Takotsubo syndrome (TTS) is associated with a substantial rate of adverse events. We sought to design a machine learning (ML)-based model to predict the risk of in-hospital death and to perform a clustering of TTS patients to identify different risk profiles.

METHODS AND RESULTS

A ridge logistic regression-based ML model for predicting in-hospital death was developed on 3482 TTS patients from the International Takotsubo (InterTAK) Registry, randomly split in a train and an internal validation cohort (75% and 25% of the sample size, respectively) and evaluated in an external validation cohort (1037 patients). Thirty-one clinically relevant variables were included in the prediction model. Model performance represented the primary endpoint and was assessed according to area under the curve (AUC), sensitivity and specificity. As secondary endpoint, a K-medoids clustering algorithm was designed to stratify patients into phenotypic groups based on the 10 most relevant features emerging from the main model. The overall incidence of in-hospital death was 5.2%. The InterTAK-ML model showed an AUC of 0.89 (0.85-0.92), a sensitivity of 0.85 (0.78-0.95) and a specificity of 0.76 (0.74-0.79) in the internal validation cohort and an AUC of 0.82 (0.73-0.91), a sensitivity of 0.74 (0.61-0.87) and a specificity of 0.79 (0.77-0.81) in the external cohort for in-hospital death prediction. By exploiting the 10 variables showing the highest feature importance, TTS patients were clustered into six groups associated with different risks of in-hospital death (28.8% vs. 15.5% vs. 5.4% vs. 1.0.8% vs. 0.5%) which were consistent also in the external cohort.

CONCLUSION

A ML-based approach for the identification of TTS patients at risk of adverse short-term prognosis is feasible and effective. The InterTAK-ML model showed unprecedented discriminative capability for the prediction of in-hospital death.

Impact of cryoballoon application abortion due to phrenic nerve injury on reconnection rates: a YETI subgroup analysis

AIMS

Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury (PNI) which is leading to premature abortion of the freeze cycle. Here, we analysed reconnection rates after CB-based PVI and PNI in a large-scale population during repeat procedures.

METHODS AND RESULTS

In the YETI registry, a total of 17 356 patients underwent CB-based PVI in 33 centres, and 731 (4.2%) patients experienced PNI. A total of 111/731 (15.2%) patients received a repeat procedure for treatment of recurrent AF. In 94/111 (84.7%) patients data on repeat procedures were available. A total of 89/94 (94.7%) index pulmonary veins (PVs) have been isolated during the initial PVI. During repeat procedures, 22 (24.7%) of initially isolated index PVs showed reconnection. The use of a double stop technique did non influence the PV reconnection rate (P = 0.464). The time to PNI was 140.5 ± 45.1 s in patients with persistent PVI and 133.5 ± 53.8 s in patients with reconnection (P = 0.559). No differences were noted between the two populations in terms of CB temperature at the time of PNI (P = 0.362). The only parameter associated with isolation durability was CB temperature after 30 s of freezing. The PV reconnection did not influence the time to AF recurrence.

CONCLUSION

In patients with cryoballon application abortion due to PNI, a high rate of persistent PVI rate was found at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT03645577?term=YETI&cntry=DE&draw=2&rank=1 ClinicalTrials.gov Identifier: NCT03645577.

Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients: insights from a multicenter registry

BACKGROUND

The subcutaneous ICD established its role in the prevention of sudden cardiac death in recent years. The occurrence of premature battery depletion in a large subset of potentially affected devices has been a cause of concern. The incidence of premature battery depletion has not been studied systematically beyond manufacturer-reported data.

METHODS

Retrospective data and the most recent follow-up data on S-ICD devices from fourteen centers in Europe, the US, and Canada was studied. The incidence of generator removal or failure was reported to investigate the incidence of premature S-ICD battery depletion, defined as battery failure within 60 months or less.

RESULTS

Data from 1054 devices was analyzed. Premature battery depletion occurred in 3.5% of potentially affected devices over an observation period of 49 months.

CONCLUSIONS

The incidence of premature battery depletion of S-ICD potentially affected by a battery advisory was around 3.5% after 4 years in this study. Premature depletion occurred exclusively in devices under advisory. This is in line with the most recently published reports from the manufacturer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04767516 .

Novel cryoballoon ablation system for pulmonary vein isolation: multicenter assessment of efficacy and safety-ANTARCTICA study

AIMS

Pulmonary vein isolation (PVI) either by balloon devices or radiofrequency forms the cornerstone of invasive atrial fibrillation (AF) treatment. Although equally effective cryoballoon (CB)-based PVI offers shorter procedure duration and a better safety profile. Beside the worldwide established Arctic Front Advance system, a novel CB device, POLARx, was recently introduced. This CB incorporates unique features, which may translate into improved efficacy and safety. However, multicentre assessment of periprocedural efficacy and safety is lacking up to date.

METHODS AND RESULTS

A total of 317 patients with paroxysmal or persistent AF were included and underwent POLARx CB-based PVI in 6 centres from Germany and Italy. Acute efficacy and safety were assessed in this prospective multicenter observational study. In 317 patients [mean age: 64 ± 12 years, 209 of 317 (66%) paroxysmal AF], a total of 1256 pulmonary veins (PVs) were identified and 1252 (99,7%) PVs were successfully isolated utilizing mainly the short tip POLARx CB (82%). The mean minimal CB temperature was -57.9 ± 7°C. Real-time PVI was registered in 72% of PVs. The rate of serious adverse events was 6.0% which was significantly reduced after a learning curve of 25 cases (9.3% vs. 3.0%, P = 0.018). The rate of recurrence-free survival after mean follow-up of 226 ± 115 days including a 90-day blanking period was 86.1%.

CONCLUSION

In this large multicentre assessment, the novel POLARx CB shows a promising efficacy and safety profile after a short learning curve.

Substrate-based ablation of atypical atrial flutter in patients with atrial cardiomyopathy

Background

Standard therapy of atypical atrial flutter (AFL) aims at deploying ablation lines between two non-conducting anatomical structures, thereby creating a line of block within the re-entry circuit. We have developed an ablation strategy, where we incorporate voltage information as a surrogate for atrial fibrosis from the electro-anatomical map (EAM) during AFL ablation procedures to create individualized, substrate-based ablation lines along the area of most pronounced low-voltage within the reentry-circuit.

Objective

The aim of this study was to evaluate acute procedural success and long-term outcome of a substrate-based ablation (SBA) strategy in comparison to a standard anatomically based ablation (ABA) strategy for the ablation of atypical AFL.

Methods

Patients that underwent ablation for AFL at our institution were included. SBA procedures were compared to ABA procedures. Endpoints were acute termination of AFL and recurrence of the index AFL or any other AFL during follow-up.

Results

We included 47 patients, 24 individuals (51.1%) in the SBA group and 23 patients (48.9%) in the ABA group. Most patients had signs of atrial cardiomyopathy, namely enlarged left atrial diameter (LAD) and extended amount of left atrial low-voltage areas (LVA). Termination of AFL occurred in 27 of 29 (93.1%) AFL in the SBA group and in 28 of 31 (90.3%) AFL in the ABA group (p = 0.99). Freedom from recurrence of any atypical AFL after 2.5 years was 21.5% in the ABA group compared to 48.8% in the SBA group (p = 0.047).

Conclusion

Substrate-based ablation is as effective as an anatomically-based ablation in the acute termination of AFL but yields better rhythm outcome with less recurrence of AFL in patients with atrial cardiomyopathy.

Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalizations

Background

During the COVID-19 pandemic, in anticipation of a demand surge for high-care hospital beds, many hospitals postponed non-emergency interventions of cardiac patients.

Aim

The aim of this study was to assess the outcomes of cardiac patients whose non-emergency interventions had been deferred during the COVID-19 pandemic.

Methods

Patients whose non-emergency cardiac intervention had been cancelled between March 19th and April 30th, 2020 were included (study group). All patients were considered as deferrable according to current recommendations. Patients’ outcomes after 12 months were compared to a seasonal control group who underwent non-emergency interventions in 2019 as scheduled. The primary endpoint was a composite of emergency cardiovascular hospitalization and death. Secondary endpoints were levels of symptoms and cardiac biomarkers.

Results

Outcomes of 193 consecutive patients in the study group were assessed and compared to 216 controls. The primary endpoint occurred significantly more often in the study group (HR 2.42, 95%CI 1.63–3.61, p < 0.001). This was driven by an increase in hospitalizations. Subgroup analyses showed that especially patients with a deferred transcatheter heart valve intervention experienced early emergency hospitalization (HR 9.55, 95%CI 3.70–24.62, p < 0.001). These findings were accompanied by more pronounced symptoms and higher biomarker levels.

Conclusions

Deferral of non-emergency cardiac interventions to meet the higher demand for hospital beds during the COVID-19 crisis is associated with early emergency cardiovascular hospitalizations. Patients suffering from valvular heart disease especially constitute a vulnerable group. Consequently, our results suggest that current recommendations on the management of cardiovascular disease during the COVID-19 pandemic need revision.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-02032-z.

Incidence of premature battery depletion in subcutaneous cardioverter-defibrillator patients. Insights from a multicenter registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

A subset of more than 35,000 S-ICD is under FDA advisory, warning of the potential of premature battery depletion (PBD), caused by a faulty low-voltage capacitor. Based on internal data, the manufacturer projects the incidence at 3.7% after 5 years. Data independent from the manufacturer is sparse.

Methods

This study was a multicenter effort of 14 centers in Europe, the US, and Canada. Consecutive patients who received a S-ICD at the participating centers were included in this retrospective analysis. Patients with the 1010 S-ICD generator model, and those without available follow-up information were excluded. Data was collected and managed using REDCap electronic data capture tools hosted at the University Hospital Cologne.

The primary endpoint in this registry was device explantation, generator replacement, or generator failure. Reasons for explantation, replacement, or failure were collected. Device longevity was defined in months. It was calculated as the time from device insertion to the time of replacement, or explantation, or failure, where applicable. Premature battery depletion was defined as the occurrence of battery depletion requiring generator replacement after 60 months or less.

The study complies with the Declaration of Helsinki. Ethics committee approval was obtained. This study is registered with Clinicaltrials.gov.

Results

Data of n=1,102 S-ICD devices was analyzed. The registry comprised of S-ICD generators implanted between 03/2015 and 09/2021 (43.4% A209 model and 56.6% A219 model). Of these, 611 devices (55.4%) were identified by the Boston Scientific serial number lookup tool as affected by the advisory. The mean and median follow-up duration was 2.43±1.66 and 2.29 years, respectively.

During follow-up, 110 devices (10%) were explanted after 2.9±1.7 years. Battery depletion was the indication in 52. The endpoint of PBD (battery depletion after less than 5 years) was met in 37 devices (6% of the devices under advisory), after 4.1±0.6 years.

In 58 cases, the S-ICD was explanted for reasons other than battery depletion.

Infection (16), system upgrade (20), heart transplant or LVAD therapy (7), and inappropriate shocks or inappropriate sensing (7) were the most common indications.

Discussion

This registry provides a systematic and manufacturer independent analysis of premature battery depletion in S-ICD patients. In the affected devices, the incidence of premature battery occurred in 6%. This is higher than what is projected by the manufacturer. The rate of PBD increases notably around the 4-year mark.

Conclusion

S-ICD generators under advisory suffer from PBD at a higher incidence than previously reported. Patients equipped with these devices should be closely monitored.

Repeat procedures and reconnection rates after cryoballoon PVI with phrenic nerve injury

Funding Acknowledgements

Type of funding sources: None.

Aims

Cryoballoon (CB) based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury which is leading to premature abortion of the freeze cycle. Here we analysed repeat procedures and reconnection rates after CB-based PVI and phrenic nerve injury in a large-scale population. Due to the fact that the freezing process was prematurely interrupted the data may offer unique findings in optimizing the CB dosing protocols.

Methods and Results

In the YETI registry a total of 17356 patients underwent CB-based PVI in 33 centers and 731 (4.2%) patients experienced phrenic nerve injury. A total of 111 / 731 (15.2%) patients received a repeat procedure utilizing a 3D mapping system due to AF recurrence. In 94/111 (84.7%) of patients data on repeat procedures was available. During their initial PVI procedures, phrenic nerve injury occurred during treatment of RSPV (n=80), RIPV (n=13) and LSPV (n=1). A total of 89/94 (94.7%) target PVs have been isolated during the initial PVI (RSPV: 75/80, 94%; RIPV: 13/13; 100%; LSPV: 1/1; 100%). The mean freezing time was 127±46s and the mean minimal temperature was -49±7°C. During the repeat procedures 67 of initially 89 isolated PVs showed persistent isolation (75%, for RSPV: 55/75; 73%; RIPV: 11/13; 85%; LSPV: 1/1; 100%).

Conclusion

In patients initially treated by CB-based PVI with interruption of the freezing due to phrenic nerve injury, a high rate of durable isolated PVs has been detected at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures

Real-Time Spiral CMR Is Superior to Conventional Segmented Cine-Imaging for Left-Ventricular Functional Assessment in Patients with Arrhythmia

(1) Background: Segmented Cartesian Cardiovascular magnetic resonance (CMR) often fails to deliver robust assessment of cardiac function in patients with arrhythmia. We aimed to assess the performance of a tiny golden-angle spiral real-time CMR sequence at 1.5 T for left-ventricular (LV) volumetry in patients with irregular heart rhythm; (2) Methods: We validated the real-time sequence against the standard breath-hold segmented Cartesian sequence in 32 patients, of whom 11 presented with arrhythmia. End-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) were assessed. In arrhythmic patients, real-time and standard Cartesian acquisitions were compared against a reference echocardiographic modality; (3) Results: In patients with sinus rhythm, good agreements and correlations were found between the segmented and real-time methods, with only minor, non-significant underestimation of EDV for the real-time sequence (135.95 ± 30 mL vs. 137.15 ± 31, p = 0.164). In patients with arrhythmia, spiral real-time CMR yielded superior image quality to the conventional segmented imaging, allowing for excellent agreement with the reference echocardiographic volumetry. In contrast, in this cohort, standard Cartesian CMR showed significant underestimation of LV-ESV (106.72 ± 63.51 mL vs. 125.47 ± 72.41 mL, p = 0.026) and overestimation of LVEF (42.96 ± 10.81% vs. 39.02 ± 11.72%, p = 0.039); (4) Conclusions: Real-time spiral CMR improves image quality in arrhythmic patients, allowing reliable assessment of LV volumetry.

Predicting Phrenic Nerve Palsy in Patients Undergoing Atrial Fibrillation Ablation With the Cryoballoon-Does Sex Matter?

Background: Phrenicus nerve palsy (PNP) is a typical complication during pulmonary vein isolation (PVI) using the cryoballoon with the ominous potential to counteract the clinical benefit of restored sinus rhythm. According to current evidence incidence of PNP is about 5–10% of patients undergoing Cryo-PVI and is more frequent during ablation of the RSPV compared to the RIPV. However, information on patient specific characteristics predicting PNP and long-term outcome of patients suffering from this adverse event is sparse.

Aim of the Study: To evaluate procedural and clinical characteristics of AF patients with PNP during cryoballoon PVI compared to patients without PNP.

Methods and Results: Between 2013 and 2019 we included 632 consecutive AF patients undergoing PVI with the cryoballoon in our study. 84/632 (13.3%) patients experienced a total number of 89 PNP during the ablation procedure. 75/89 (84%) cryothermal induced PNP recovered until the end of the procedure (transient PNP, tPNP), whereas 14/89 (16%) PNP hold beyond the end of the procedure (non-transient PNP, ntPNP). Using multivariate logistic regression, we found that sex and BMI are strong and independent predictors of cryothermal induced non-transient PNP during cryoballoon PVI with an odds ratio of 3.9 (CI: 95%, 1.1–14.8, p = 0.04) for female gender. Interestingly, all patients (14/14, 100%) with a non-transient PNP experienced complete PNP resolution after a mean recovery time of 68 ± 79 days.

Conclusion: Our data indicate for the first time, that female sex and lower BMI are independent predictors for non-transient PNP caused by cryoballoon PVI. Fortunately, during follow up all PNP patients resolved completely with a median recovery time of 35 days.

Phrenic Nerve Injury During Cryoballoon-Based Pulmonary Vein Isolation: Results of the Worldwide YETI Registry

Supplemental Digital Content is available in the text.

Background:

Cryoballoon-based pulmonary vein isolation (PVI) has emerged as an effective treatment for atrial fibrillation. The most frequent complication during cryoballoon-based PVI is phrenic nerve injury (PNI). However, data on PNI are scarce.

Methods:

The YETI registry is a retrospective, multicenter, and multinational registry evaluating the incidence, characteristics, prognostic factors for PNI recovery and follow-up data of patients with PNI during cryoballoon-based PVI. Experienced electrophysiological centers were invited to participate. All patients with PNI during CB2 or third (CB3) and fourth-generation cryoballoon (CB4)-based PVI were eligible.

Results:

A total of 17 356 patients underwent cryoballoon-based PVI in 33 centers from 10 countries. A total of 731 (4.2%) patients experienced PNI. The mean time to PNI was 127.7±50.4 seconds, and the mean temperature at the time of PNI was −49±8°C. At the end of the procedure, PNI recovered in 394/731 patients (53.9%). Recovery of PNI at 12 months of follow-up was found in 97.0% of patients (682/703, with 28 patients lost to follow-up). A total of 16/703 (2.3%) reported symptomatic PNI. Only 0.06% of the overall population showed symptomatic and permanent PNI. Prognostic factors improving PNI recovery are immediate stop at PNI by double-stop technique and utilization of a bonus-freeze protocol. Age, cryoballoon temperature at PNI, and compound motor action potential amplitude loss >30% were identified as factors decreasing PNI recovery. Based on these parameters, a score was calculated. The YETI score has a numerical value that will directly represent the probability of a specific patient of recovering from PNI within 12 months.

Conclusions:

The incidence of PNI during cryoballoon-based PVI was 4.2%. Overall 97% of PNI recovered within 12 months. Symptomatic and permanent PNI is exceedingly rare in patients after cryoballoon-based PVI. The YETI score estimates the prognosis after iatrogenic cryoballoon-derived PNI.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03645577.

Graphic Abstract:

A graphic abstract is available for this article.

Histone deacetylase 1 controls cardiomyocyte proliferation during embryonic heart development and cardiac regeneration in zebrafish

In contrast to mammals, the zebrafish maintains its cardiomyocyte proliferation capacity throughout adulthood. However, neither the molecular mechanisms that orchestrate the proliferation of cardiomyocytes during developmental heart growth nor in the context of regeneration in the adult are sufficiently defined yet. We identified in a forward genetic N-ethyl-N-nitrosourea (ENU) mutagenesis screen the recessive, embryonic-lethal zebrafish mutant baldrian (bal), which shows severely impaired developmental heart growth due to diminished cardiomyocyte proliferation. By positional cloning, we identified a missense mutation in the zebrafish histone deacetylase 1 (hdac1) gene leading to severe protein instability and the loss of Hdac1 function in vivo. Hdac1 inhibition significantly reduces cardiomyocyte proliferation, indicating a role of Hdac1 during developmental heart growth in zebrafish. To evaluate whether developmental and regenerative Hdac1-associated mechanisms of cardiomyocyte proliferation are conserved, we analyzed regenerative cardiomyocyte proliferation after Hdac1 inhibition at the wound border zone in cryoinjured adult zebrafish hearts and we found that Hdac1 is also essential to orchestrate regenerative cardiomyocyte proliferation in the adult vertebrate heart. In summary, our findings suggest an important and conserved role of Histone deacetylase 1 (Hdac1) in developmental and adult regenerative cardiomyocyte proliferation in the vertebrate heart.

Heart disease is one of the most common causes of death in all developed countries. While zebrafish cardiomyocytes are able to proliferate throughout adulthood, mammalian cardiomyocytes lose this ability during early development, and therefore are not capable to replace and renew cardiomyocytes after injury. The underlying mechanisms of cardiomyocyte proliferation are still not completely resolved. Understanding how zebrafish cardiomyocytes preserve their proliferating state, would be a valuable information to foster cardiac regeneration, e.g. after myocardial infarction in patients. Knowledge of the signaling pathways that need to be activated, or deactivated in order to induce cardiomyocyte proliferation after acute or chronic injury will pave the way for the development of genetic and/or pharmacological treatment options. In an ENU-mutagenesis screen, we identified the zebrafish mutant baldrian, which shows reduced embryonic cardiomyocyte proliferation. As genetic cause of the observed phenotype, we identified a missense mutation in the hdac1 gene. By treatment of heart-injured adult fish with the HDAC1 inhibitor Mocetinostat, we were able to show a reduced rate of cardiomyocyte proliferation also in the adult zebrafish heart in vivo, suggesting a role of Hdac1 in embryonic heart growth and adult regenerative cardiomyocyte proliferation in zebrafish.

Catheter ablation for atrial fibrillation in HFpEF patients-A propensity-score-matched analysis

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are both common conditions associated with high morbidity and mortality, especially if they coexist. Catheter ablation (CA) for AF has been shown recently to induce reverse remodeling and improve symptoms in HFpEF patients. The aim of this study was to compare outcomes of AF patients with HFpEF, who either underwent CA for AF or received medical therapy only.

METHODS AND RESULTS

We included all AF patients with HFpEF according to current guidelines treated at our hospital between 2013 and 2018. Out of 6614 AF patients, we identified 127 with confirmed HFpEF. After applying propensity score matching to balance patient groups, 43 patients treated by CA and 43 patients receiving medical treatment were compared. Patients in the CA group underwent a mean of 1.5 ± 0.8 ablation procedures. Arrhythmia recurrence occurred significantly less frequently in the CA group (hazard ratio [HR]: 0.47; 95% CI: 0.25-0.87; p = .016). The primary endpoint, a composite of heart failure hospitalization and death, was reduced significantly by CA compared to medical therapy (HR: 0.30; 95% CI: 0.13-0.67; p = .003). This was driven by a decrease in heart failure hospitalization. Clinical and echocardiographic parameters of HFpEF improved significantly only after CA. Remarkably, reassessment of diagnostic HFpEF criteria at the end of follow-up demonstrated HFpEF resolution in 15 out of 43 patients (35%) treated by CA and only 4 out of 43 patients (9%) treated medically (p = .008).

CONCLUSION

Catheter ablation for AF in HFpEF patients in comparison to medical therapy decreases heart failure hospitalization, heart failure symptoms, and improves diastolic function. AF ablation should be considered in patients with HFpEF and concomitant AF.

Impact of Atrial Fibrillation on Outcome in Takotsubo Syndrome: Data From the International Takotsubo Registry

Background

Atrial fibrillation (AF) is a major risk factor for mortality. The prevalence, clinical correlates, and prognostic impact of AF in Takotsubo syndrome (TTS) have not yet been investigated in a large patient cohort. This study aimed to investigate the prevalence, clinical correlates, and prognostic impact of AF in patients with TTS.

Methods and Results

Patients with TTS were enrolled from the International Takotsubo Registry, which is a multinational network with 26 participating centers in Europe and the United States. Patients were dichotomized according to the presence or absence of AF at the time of admission. Of 1584 patients with TTS, 112 (7.1%) had AF. The mean age was higher (P<0.001), and there were fewer women (P=0.046) in the AF than in the non‐AF group. Left ventricular ejection fraction was significantly lower (P=0.001), and cardiogenic shock was more often observed (P<0.001) in the AF group. Both in‐hospital (P<0.001) and long‐term mortality (P<0.001) were higher in the AF group. Multivariable Cox regression analysis revealed that AF was independently associated with higher long‐term mortality (hazard ratio, 2.31; 95% CI, 1.50–3.55; P<0.001). Among patients with AF on admission, 42% had no known history of AF before the acute TTS event, and such patients had comparable in‐hospital and long‐term outcomes compared with those with a history of AF.

Conclusions

In patients presenting with TTS, AF on admission is significantly associated with increased in‐hospital and long‐term mortality rates. Whether antiarrhythmics and/or cardioversion are beneficial in TTS with AF should thus be tested in a future trial.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01947621.

Restoration of sinus rhythm by pulmonary vein isolation improves heart failure with preserved ejection fraction in atrial fibrillation patients

Aims

Atrial fibrillation (AF) in patients suffering from heart failure with preserved ejection fraction (HFpEF) is associated with increased symptoms and higher morbidity and mortality. Effective treatment strategies for this patient population have not yet been established.

Methods and results

We analysed clinical outcomes and echocardiographic parameters of patients with AF and HFpEF who underwent pulmonary vein isolation (PVI). Out of 374 PVI patients, we identified 35 patients suffering from concomitant HFpEF. Freedom from atrial tachyarrhythmia (AT) after 1 year was 80%. Heart failure symptoms assessed by New York Heart Association class significantly improved from 2.7 ± 0.7 to 1.7 ± 0.9 (P < 0.001). We observed regression of diastolic dysfunction by echocardiography 12 months after the index procedure. Moreover, 15 patients (42.9%) experienced complete resolution of HFpEF after a single ablation procedure. Multivariate logistic regression revealed absence of AT recurrence as an independent predictor of recovery from HFpEF (hazard ratio 11.37, 95% confidence interval 1.70–75.84, P = 0.009). Furthermore, resolution of HFpEF by achieving freedom from AT recurrence by PVI, including multiple procedures, led to a significant reduction of hospitalizations.

Conclusion

Our results suggest that restoration of sinus rhythm by PVI in HFpEF patients with concomitant AF induces reverse remodelling, improvement of symptoms, resolution of HFpEF and subsequently decrease of hospitalizations. Randomized controlled trials are warranted to confirm our results.

Coexistence and outcome of coronary artery disease in Takotsubo syndrome

AIMS

Takotsubo syndrome (TTS) is an acute heart failure syndrome, which shares many features with acute coronary syndrome (ACS). Although TTS was initially described with angiographically normal coronary arteries, smaller studies recently indicated a potential coexistence of coronary artery disease (CAD) in TTS patients. This study aimed to determine the coexistence, features, and prognostic role of CAD in a large cohort of patients with TTS.

METHODS AND RESULTS

Coronary anatomy and CAD were studied in patients diagnosed with TTS. Inclusion criteria were compliance with the International Takotsubo Diagnostic Criteria for TTS, and availability of original coronary angiographies with ventriculography performed during the acute phase. Exclusion criteria were missing views, poor quality of angiography loops, and angiography without ventriculography. A total of 1016 TTS patients were studied. Of those, 23.0% had obstructive CAD, 41.2% had non-obstructive CAD, and 35.7% had angiographically normal coronary arteries. A total of 47 patients (4.6%) underwent percutaneous coronary intervention, and 3 patients had acute and 8 had chronic coronary artery occlusion concomitant with TTS, respectively. The presence of CAD was associated with increased incidence of shock, ventilation, and death from any cause. After adjusting for confounders, the presence of obstructive CAD was associated with mortality at 30 days. Takotsubo syndrome patients with obstructive CAD were at comparable risk for shock and death and nearly at twice the risk for ventilation compared to an age- and sex-matched ACS cohort.

CONCLUSIONS

Coronary artery disease frequently coexists in TTS patients, presents with the whole spectrum of coronary pathology including acute coronary occlusion, and is associated with adverse outcome.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT01947621.

Prognostic impact of acute pulmonary triggers in patients with takotsubo syndrome: new insights from the International Takotsubo Registry

AIMS

Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes.

METHODS AND RESULTS

Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In-hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long-term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long-term mortality (hazard ratio 2.12, 95% confidence interval 1.33-3.38; P = 0.002).

CONCLUSIONS

The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in-hospital course and a worse long-term outcome.

Impact of bleeding complications after transcatheter mitral valve repair

BACKGROUND

Bleeding in the context of cardiac catheterization is frequent and negatively impacts on short- and long-term patient outcome. We evaluated the clinical impact of in-hospital bleeding events after transcatheter mitral valve repair (TMVr) in the long-term follow- up.

METHODS

586 consecutive patients treated with first-time TMVr were enrolled in this registry. In-hospital MVARC (Mitral Valve Academic Research Council) bleedings were assessed and patients were grouped according to the incidence of a bleeding event. Multivariate logistic regression was used to identify significant independent predictors of MVARC bleeding. This study received approval by local ethics committee.

RESULTS

78 patients (13.3%) suffered from an MVARC bleeding event (Access site-related bleedings: 46.2%; GI tract bleeding: 35.9%; Other bleedings: 17.9%). Among these bleeding subgroups, neither relevant differences in baseline characteristics nor in severity of bleeding events were observed. Despite not being an independent predictor for overall death in the multivariate Cox regression analysis, MVARC bleeding was associated with prolonged hospital stay. The ORBIT bleeding score was the best match to predictors of any MVARC bleeding found in our cohort (c-score overall cohort: 0.68; c-score GI bleeding cohort: 0.72).

CONCLUSION

MVARC bleedings after TMVr are frequent findings but were only in half of the cases related to the access site. The ORBIT score could be useful for identification of patients at high risk for non-access site bleeding and especially GI bleeding.

Age-Related Variations in Takotsubo Syndrome

BACKGROUND

Takotsubo syndrome (TTS) occurs predominantly in post-menopausal women but is also found in younger patients.

OBJECTIVES

This study aimed to investigate age-related differences in TTS.

METHODS

Patients diagnosed with TTS and enrolled in the International Takotsubo Registry between January 2011 and February 2017 were included in this analysis and were stratified by age (younger: ≤50 years, middle-age: 51 to 74 years, elderly: ≥75 years). Baseline characteristics, hospital course, as well as short- and long-term mortality were compared among groups.

RESULTS

Of 2,098 TTS patients, 242 (11.5%) patients were ≤50 years of age, 1,194 (56.9%) were 51 to 74 years of age, and 662 (31.6%) were ≥75 years of age. Younger patients were more often men (12.4% vs. 10.9% vs. 6.3%; p = 0.002) and had an increased prevalence of acute neurological (16.3% vs. 8.4% vs. 8.8%; p = 0.001) or psychiatric disorders (14.1% vs. 10.3% vs. 5.6%; p < 0.001) compared with middle-aged and elderly TTS patients. Furthermore, younger patients had more often cardiogenic shock (15.3% vs. 9.1% vs. 8.1%; p = 0.004) and had a numerically higher in-hospital mortality (6.6% vs. 3.6% vs. 5.1%; p = 0.07). At multivariable analysis, younger (odds ratio: 1.60; 95% confidence interval: 0.86 to 3.01; p = 0.14) and older age (odds ratio: 1.09; 95% confidence interval: 0.66 to 1.80; p = 0.75) were not independently associated with in-hospital mortality using the middle-aged group as a reference. There were no differences in 60-day mortality rates among groups.

CONCLUSIONS

A substantial proportion of TTS patients are younger than 50 years of age. TTS is associated with severe complications requiring intensive care, particularly in younger patients.

[It's all over! : Complications in the EP lab and their solutions]

In cardiac electrophysiology, invasive procedures like catheter ablations or device implantations are getting increasingly complex. This poses challenges especially for electrophysiologists in training, not only to learn how to perform the procedure, but also how to manage possible complications. The present article uses exemplary case studies to present how to control complications and how to avoid them. The presented cases deal with complications such as air embolism in left atrial procedures, iatrogenic vascular injuries such as aortic dissection or dissection of the coronary sinus, complications and challenges with lead revisions, and pericardial tamponade. In each case, measures for avoidance as well as practical guidance for management are shown when the respective complication occurs.

Safety of conscious sedation in electroanatomical mapping procedures and cryoballoon pulmonary vein isolation

Immobilization of patients during electrophysiological procedures, to avoid complications by patients' unexpected bodily motion, is achieved by moderate to deep conscious sedation using benzodiazepines and propofol for sedation and opioids for analgesia. Our aim was to compare respiratory and hemodynamic safety endpoints of cryoballoon pulmonary vein isolation (PVI) and electroanatomical mapping (EAM) procedures. Included patients underwent either cryoballoon PVI or EAM procedures. Sedation monitoring included non-invasive blood pressure measurements, transcutaneous oxygen saturation (tSpO₂) and transcutaneous carbon-dioxide (tpCO₂) measurements. We enrolled 125 consecutive patients, 67 patients underwent cryoballoon atrial fibrillation ablation and 58 patients had an EAM and radiofrequency ablation procedure. Mean procedure duration of EAM procedures was significantly longer (p < 0.001) and propofol doses as well as morphine equivalent doses of administered opioids were significantly higher in EAM patients compared to cryoballoon patients (p < 0.001). Cryoballoon patients display higher tpCO₂ levels compared to EAM patients at 30 min (cryoballoon: 51.1 ± 7.0 mmHg vs. EAM: 48.6 ± 6.2 mmHg, p = 0.009) and at 60 min (cryoballoon: 51.4 ± 7.3 mmHg vs. EAM: 48.9 ± 6.6 mmHg, p = 0.07) procedure duration. Mean arterial pressure was significantly higher after 60 min (cryoballoon: 84.7 ± 16.7 mmHg vs. EAM: 76.7 ± 13.3 mmHg, p = 0.017) in cryoballoon PVI compared to EAM procedures. Regarding respiratory and hemodynamic safety endpoints, no significant difference was detected regarding hypercapnia, hypoxia and episodes of hypotension. Despite longer procedure duration and deeper sedation requirement, conscious sedation in EAM procedures appears to be as safe as conscious sedation in cryoballoon ablation procedures regarding hemodynamic and respiratory safety endpoints.

Continuous, transcutaneous carbon-dioxide monitoring to avoid hypercapnia in complex catheter ablations under conscious sedation

Background

Ablation of complex cardiac arrhythmias requires an immobilized patient. For a successful and safe intervention and for patient comfort, this can be achieved by conscious sedation. Administered sedatives and analgesics have respiratory depressant side effects and require close monitoring.

Purpose

We investigated the feasibility and accuracy of an additional, continuous transcutaneous carbon-dioxide partial pressure (tpCO2) measurement during conscious sedation in complex electrophysiological catheter ablation procedures.

Methods

We evaluated the accuracy and additional value of tpCO2 detection by application of a Severinghaus electrode in comparison to arterial and venous blood gas analyses.

Results

We included 110 patients in this prospective observational study. Arterial pCO2 (paCO2) and tpCO2 showed good correlation throughout the procedures (r=0.60–0.87, p&lt;0.005). Venous pCO2 (pvCO2) were also well correlated to transcutaneous values (r=0.65–0.85, p&lt;0.0001). Analyses of the difference of pvCO2 and tpCO2 measurements showed a tolerance within &lt;10mmHg in up to 96–98% of patients. Hypercapnia (pCO2&lt;70mmHg) was detected more likely and earlier by continuous tpCO2 monitoring compared to half-hourly pvCO2 measurements.

Conclusion

Continuous tpCO2 monitoring is feasible and precise with good correlation to arterial and venous blood gas carbon-dioxide analysis during complex catheter ablations under conscious sedation and may contribute to additional safety.

Funding Acknowledgement

Type of funding source: None

Toxicity and phytochemistry of eight species used in the traditional medicine of sul-mato-grossense, Brazil

Abstract The Brazilian Cerrado has several botanical species for medicinal purposes used by traditional communities and many of these plants are not included in the list of Medicinal Plants Research Program of Central Medicines. The purpose of this study was the phytochemical screening and toxicology bioassay front of Brine shrimp L. of ethanolic extracts of eight species of plants used in folk medicine of Campo Grande, Mato Grosso do Sul, Brazil. The ethanolic extracts were submitted to phytochemical screening, determination of phenolic compounds and flavonoids. Toxicological assays were carried front of Brine shrimp according to standard methodology. The analysis TLC and HPLC-DAD confirmed the predominance of phenolic compounds and derivatives, specifically for the quercetin. The most toxic was the C. affinis DC. with death at all concentrations, the A. humile A. St. Hil. showed no mortality and the other species showed intermediate toxicity. The extracts of the investigated species are rich in phenolic compounds and derivatives, specifically quercetin, and feature toxicity between moderate to high, a fact that requires attention, since much of the traditional communities rely on herbal drugs in its raw form with preventive and curative purpose, meeting the basic health care.

Atrial fibrillation ablation in heart failure patients: improved systolic function after cryoballoon pulmonary vein isolation

Aims

Atrial fibrillation (AF) and heart failure (HF) are the most common cardiac diseases and often coexist leading to increased mortality and morbidity compared with AF patients without HF. As shown previously, AF ablation using radio frequency (RF) in HF patients leads to a reduction of AF burden, an increase of left ventricular ejection fraction (LVEF) and consequently to reduced hospitalization and mortality. Previous AF ablation studies on HF patients have been liberal about additional targets beyond pulmonary vein isolation (PVI). Thus, the aim of this study was to assess systematically the impact of a straightforward PVI‐only strategy on LVEF, NYHA functional class, and cardiovascular hospitalization rate in HF patients.

Methods and results

Out of 414 consecutive patients undergoing PVI, only with the cryoballoon 113 patients with reduced LVEF [mean: 38.4 ± 10.8%, reduced ejection fraction (rEF) group] and 301 patients with normal LVEF (>55%) at baseline were identified [normal ejection fraction (nEF) group]. Remarkably, even though freedom from arrhythmia recurrence after 1 year was significantly lower in the rEF group (64.9%) compared with the nEF group (71.2%, P = 0.036), mean LVEF improved from 38.4 ± 10.8% to 52.5 ± 17.2% (P < 0.001) after cryoballoon ablation in the rEF group. Accordingly, HF‐related symptoms as well as hospitalization rate declined significantly in the rEF group during follow‐up compared with baseline.

Conclusions

The results of the present study suggest that catheter ablation restricted to a straightforward PVI‐only strategy using the cryoballoon leads to improved left ventricular ejection fraction as well as improvement of NYHA functional class and increased freedom from cardiovascular rehospitalization.

P1386Continuous, transcutaneous carbon-dioxide monitoring in complex electrophysiological procedures in conscious sedation - is there a safer way to sleep?

Funding Acknowledgements

Karolina Weinmann was supported by the Hertha-Nathorff fellowship from Ulm University

Background – Ablation of cardiac arrhythmias by complex electrophysiological procedures is a growing field. A moderate to deep sedation is needed to immobilize the patient to warrant a safe and effective intervention. The administrated medication to obtain an adequate sedation has respiratory depressant side effects and could cause respiratory complications, like hypercapnia and hypoxia.

Purpose – Our aim was to investigate the feasibility and accuracy of an additional, continuous transcutaneous carbon-dioxide (tpCO2) measurement during moderate to deep sedation in complex electrophysiological catheter ablations.

Methods – Consecutive patients received an electrophysiological intervention with need for deep sedation. Routine hemodynamic monitoring was performed by the measurement of non-invasive blood-pressure, oxygen saturation and half-hourly venous blood gas analysis. Additionally, patients received a tpCO2 sensor on the forehead with an automated, continuous documentation of transcutaneous oxygen saturation and carbon-dioxide. A precise sedation protocol was performed and administrated drugs were registered.

Results – We included 110 patients to the analysis. Fifty patients received cryoballoon pulmonary vein isolation, 58 patients 3D-mapping procedure and two patients ventricular tachycardia ablation. The mean procedure time was 135.1 ± 63.5 minutes and the fluoroscopy time was 21.5 ± 10.9 minutes. To achieve an adequate sedation a mean of 5.0 ± 0.8 mg midazolam, 583.8 ± 320.4 mg propofol, 72.0 ± 30.3 µg fentanyl and 0.2 ± 0.1 mg remifentanil were administrated.

Hypercapnia (pCO2 &gt; 70 mmHg) was detected in five patient by the tpCO2 monitoring and only in two patients using venous carbon-dioxide partial pressure (vpCO2) analysis. Correlation of tpCO2 and vpCO2 were analyzed half-hourly by Pearsons’ correlation coefficient. There was a good correlation during the investigated 120 minutes of procedure time (baseline: r = 0.65, p &lt; 0.0001; 30 minutes: r = 0.75, p &lt; 0.0001; 60 minutes: r = 0.77, p &lt; 0.0001; 90 minutes: r = 0.78, p &lt; 0.0001; 120 minutes: r = 0.85, p &lt; 0.0001). The detected difference between tpCO2 and vpCO2 was at baseline &lt;5 mmHg in 65% (79/110) and &lt;10 mmHg in 96% (103/110), after 30 minutes the difference was &lt;5 mmHg in 71% (78/110) and &lt;10 mmHg in 96% (105/110), after 60 minutes the difference was &lt;5 mmHg in 77% (60/78) and &lt;10 mmHg in 96% (75/78) and after 90 minutes the difference between the two methods was &lt;5 mmHg in 63% (30/48) and &lt;10 mmHg in 98% (47/48) of the cohort.

Conclusion – The continuous tpCO2 monitoring is a feasible and precise method with a good correlation to the venous blood gas carbon-dioxide analysis of the standard monitoring during complex catheter ablations in deep sedation. Randomized trials are required to further analyze if tpCO2 monitoring adds further safety to electrophysiological procedures in deep sedation.

P396Impact of re-definition of paroxysmal and persistent atrial fibrillation in the 2012 and 2016 ESC atrial fibrillation guidelines on outcomes after cryoballoon pulmonary vein

Introduction – In the 2016 European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) the definition of AF type has been modified compared to the 2010 guidelines and its 2012 focused update.

Purpose – Our aim was to compare the difference of single procedure outcomes using the definitions before and after 2016 on a cohort of patients with AF undergoing cryoballoon pulmonary vein isolation (PVI).

Methods – Consecutive PVI patients with paroxysmal or persistent AF were retrospectively reclassified applying the 2010, 2012 and 2016 ESC definitions on AF type.

Results – 628 patients were included in the analysis. Applying the 2010 ESC AF guidelines definition, 68% (425/628) of patients were categorized as paroxysmal and 32% (203/628) as persistent AF. According to the 2012 focused update 77% (485/628) are labeled paroxysmal and 23% (143/628) are persistent AF. Applying the 2016 ESC AF guidelines, the proportion of patients with paroxysmal AF increased to 87% (546/628) of patients and the patients with persistent AF decreased to 13% (82/628).

Comparing the 2010 and 2016 ESC AF type definitions, 123 patients shift from the 2010 persistent group to the 2016 paroxysmal group. Age, left ventricular ejection fraction (LVEF), LA diameter and CHA2DS2-VASc Score differ significantly between paroxysmal and persistent AF patients according to the 2010, 2012, and 2016 AF type classification. Regarding outcomes, recurrence rates of paroxysmal and persistent AF patients differ significantly in Kaplan-Meier estimation applying the 2010 ESC guidelines definition (log-rank p &lt; 0.001). Applying the 2012 focused update and the 2016 ESC AF guidelines recurrence rates do not differ significantly. Persistent AF has been shown repeatedly to be a predictor of arrhythmia recurrence in PVI studies. In a cox regression model applying the 2010 guidelines, persistent AF is the only independent predictor for AF recurrence in our cohort. However, when applying the 2016 guidelines persistent AF is no longer a predictor for AF recurrence.

Conclusion – The revised definition of AF types in the 2016 ESC AF guidelines leads to a marked shift from persistent to paroxysmal AF. It appears that the old definition was a better separator to predict rhythm outcome after PVI.

P1088Effect of coronary artery disease on patients with atrial fibrillation and heart failure with preserved ejection fraction - from vicious twins to vicious triplets?

Background

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are common diseases and associated with increased morbidity and mortality, which even aggravates if both conditions are coexisting. Coronary artery disease (CAD) is highly prevalent in both, patients with AF (17-46%) and HFpEF (50-80%). Notably, all three entities share several common risk factors. While it is well established that the emergence of the vicious twins HFpEF and AF is mechanistically linked, CAD can also be pathophysiological related to HFpEF, as well as AF by several mechanisms.

Aim

The study aimed to evaluate the influence of CAD on patients with concomitant AF and HFpEF and to identify parameters affecting the patients clinical outcome.

Methods

We retrospectively screened patients with AF and HFpEF for CAD. Patients with and without CAD were compared by relevant patient characteristics and echocardiographic parameters at baseline and at the end of follow-up. Additionally, we assessed hospitalization rates and  performed multivariate logistic regression to analyze parameters influencing the clinical outcome. 

Results

Between January 2013 and December 2016 6.114 patients with atrial fibrillation and 2.187 patients with echocardiographic diastolic dysfunction were treated at our university hospital department. Of those, 127 patients had concomitant diagnosis of HFpEF according to current guidelines and AF. In 77 patients (61%) CAD had been diagnosed by coronary angiography. At baseline, CAD patients had significantly more myocardial infarction, dyslipidemia, use of aspirin, lower left ventricular ejection fraction, larger left ventricular diastolic diameter and a higher CHA2DS2-VAsc score. Moreover, CAD patients had significantly higher rates of all-cause and cardiovascular hospitalizations. Interestingly, NYHA-class and left ventricular mass index improved significantly in the group without CAD, whereas there was no change in the CAD-group. Multivariate logistic regression only associated catheter ablation for AF significantly with NYHA improvement in the total cohort. Assessment of all-cause and cardiovascular hospitalization in CAD patients undergoing either catheter ablation or medical therapy revealed, that catheter ablation significantly decreased event rates. Moreover, catheter ablation for AF was associated with echocardiographic signs of reverse remodelling, whereas conservative treatment resulted in progression of remodelling. 

Conclusion

This is the first study to evaluate the effect of CAD on patients with concomitant AF and HFpEF. As expected, presence of CAD was related to a worse clinical outcome. Interestingly, in CAD patients catheter ablation was significantly associated with functional and clinical improvement. In conclusion, catheter ablation for AF might display an effective therapeutic approach in this vulnerable population.

P568Catheter ablation for atrial fibrillation with heart failure with preserved ejection fraction

Background

Atrial fibrillation (AF) in patients suffering from heart failure with preserved ejection fraction (HFpEF) is associated with increased symptoms and higher morbidity and mortality. Effective treatment strategies for this patient population have not yet been established.

Aim

This study aimed to compare the impact of catheter ablation for AF against the current standard therapy on patients with HFpEF.

Methods

We retrospectively compared clinical outcomes and echocardiographic parameters of patients with AF and HFpEF, who either underwent medical therapy (rate or rhythm control) or catheter ablation for AF. The primary endpoint was a composite of death and hospitalization for any cause and the secondary endpoint a composite of cardiovascular death and cardiovascular hospitalization. Additionally, we assessed NYHA-class, relevant echocardiographic parameters, current ESC diagnosis criteria for HFpEF at baseline and at the end of follow-up, as well as time-to-AF recurrence in both groups. Resolution of HFpEF was estimated, if both left ventricular mass index(LVMI) and E/e’ ratio did not fulfil the ESC-criteria at the end of follow-up. 

Results

Between January 2013 and December 2018 6.114 patients were treated for AF at our university hospital department. Of those, 752 patients suffered from heart failure symptoms and had echocardiographic diastolic dysfunction. Applying the current ESC-criteria HFpEF was diagnosed in 127 patients. While 59 patients received medical therapy only, catheter ablation for AF was performed in 68 patients. Analysis of AF recurrence in both groups revealed, that in the ablation group 82% of patients and in the medical therapy group only 25% of patients were free from any atrial arrhythmia after one year. Reevaluation of echocardiographic parameters after a mean follow-up period of 39 ± 20 months showed no difference in the medical therapy group, but revealed a significant improvement of the mitral E-wave velocity, E/E’ ratio, LVMI, interventricular septal thickness, e’ velocity and left ventricular diastolic in the catheter therapy group, suggesting reverse remodeling. Reassessment of criteria for HFpEF diagnosis showed resolution of HFpEF in 35% of invasively treated patients compared to 12% of patients who received conservative therapy only (p = 0.002). Moreover, heart failure symptoms, monitored by NYHA-class, significantly worsened in the medical therapy group, whereas there was significant improvement after catheter ablation. Furthermore, assessment of the primary and secondary endpoint displayed significant lower rates of events.

Conclusion

This is the first study comparing the effect of catheter ablation for AF with the current standard therapy in patients with concomitant HFpEF. Our results suggest that catheter ablation is able to induce reverse remodeling of HFpEF, possibly thereby reducing typical heart failure symptoms and hospitalizations.

P963Recurrence of atrial fibrillation after cryoballoon pulmonary vein isolation in overweight and obese patients - does weight matter?

Funding Acknowledgements

Karolina Weinmann was supported by the Hertha-Nathorff fellowship from Ulm University

Background - Obesity is a known risk factor for the incidence and persistence of atrial fibrillation. Many interventional studies proved losing weight correlates with less atrial fibrillation (AF) burden.

Purpose – We investigated the influence of overweight and obesity on baseline characteristics, procedural values and outcome after cryoballoon pulmonary vein isolation (cryoballoon PVI).

Methods – We investigated 575 patients undergoing cryoballoon PVI at our Medical Center. 142 patients were classified as normal with a body mass index (BMI) of 18.5 – 24.9 kg/m², 239 patients presented overweight with a BMI of 25.0 – 29.9 kg/m² and 194 patients were obese with a BMI over 30.0. We compared the baseline characteristics, the procedural and outcome data of these patients.

Results – Comparing baseline characteristics of overweight and obese patients to normal weight patients, obese show the highest portion in hypertension (obese vs. normal: 86.1% vs. 68.3%, p &lt; 0.001), diabetes (26.8% vs. 14.8%, p &lt; 0.05), OSAS (17.0% vs. 2.1%, p &lt; 0.001) and left atrial (LA) diameter (44.6 ± 10.8mm vs. 41.3 ± 12.7mm, p &lt; 0.05). Comparison of procedure duration, fluoroscopy time and area dose product (Gy*cm²), only the area dose product shows a significantly higher value in the overweight and obese patients (p &lt; 0.001). Moreover, comparing the duration of ablation, time to isolation per pulmonary vein between the three groups, the overweight and obese patients show a significantly longer duration of ablation at the RSPV and the time to isolation is significantly higher at the LSPV.

Mean follow-up period in our cohort is 517.3 ± 461.3 days (1.4 ± 1.3 years). Kaplan-Meier estimation shows no significant difference between freedom from AT/AF recurrence comparing normal weight, overweight and obese patients (Log-rank p = 0.6). After one year follow-up, 70% of normal weight patients show freedom from atrial arrhythmia recurrence and 69% of overweight patients.  Obese patients have a fraction of 75% of freedom from AT/AF recurrence after one year. Comparing the two years follow-up values 56% of the normal BMI patients, 54% of the overweight patients and 62% of obese patients are free from arrhythmia recurrence.

Conclusion – Cryoballoon PVI procedure in obese and overweight patients is a feasible treatment, however the radiation exposure is higher compared to normal weight. Evaluating outcomes, no difference in recurrence of AF was detected between normal, overweight and obese patients after cryoballoon PVI.

Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome

Objective:

Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, which can contribute to intraventricular thrombus and embolism. Still, prevalence and clinical impact of thrombus formation and embolic events on outcome of TTS patients remain unclear. This study aimed to investigate clinical features and outcomes of patients with and without intraventricular thrombus or embolism. Additionally, factors associated with thrombus formation or embolism, as well as predictors for mortality, were identified.

Approach and Results:

TTS patients enrolled in the International Takotsubo Registry at 28 centers in Australia, Europe, and the United States were dichotomized according to the occurrence/absence of intraventricular thrombus or embolism. Patients with intraventricular thrombus or embolism were defined as the ThrombEmb group. Of 1676 TTS patients, 56 (3.3%) patients developed intraventricular thrombus and/or embolism following TTS diagnosis (median time interval, 2.0 days [range, 0–38 days]). Patients in the ThrombEmb group had a different clinical profile including lower left ventricular ejection fraction, higher prevalence of the apical type, elevated levels of troponin and inflammatory markers, and higher prevalence of vascular disease. In a Firth bias-reduced penalized-likelihood logistic regression model apical type, left ventricular ejection fraction ≤30%, previous vascular disease, and a white blood cell count on admission >10×10 3 cells/μL emerged as independent predictors for thrombus formation or embolism.

Conclusions:

Intraventricular thrombus or embolism occur in 3.3% of patients in the acute phase of TTS. A simple risk score including clinical parameters associated with intraventricular thrombus formation or embolism identifies patients at increased risk.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01947621.

Clinical Predictors and Prognostic Impact of Recovery of Wall Motion Abnormalities in Takotsubo Syndrome: Results From the International Takotsubo Registry

Background

Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide‐ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients.

Methods and Results

TTS patients from the International Takotsubo Registry were included in this study. Cut‐off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In‐hospital outcomes and 1‐year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P=0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P=0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1‐year outcome compared with patients with early recovery (P=0.003). On multiple logistic regression, male sex, LV ejection fraction <45%, and acute neurologic disorders were associated with the absence of early recovery.

Conclusions

TTS patients without early LV recovery have different clinical characteristics and less favorable 1‐year outcome compared with patients with early recovery. The factors associated with the absence of early recovery included male sex, reduced LV ejection fraction, and acute neurologic events.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.

6121Phrenic nerve injury during pulmonary vein isolation using the second-generation cryoballoon: characteristics and follow-up - The YETI registry

Background

Second-generation cryoballoon (CB2) based pulmonary vein isolation (PVI) has emerged as a safe and effective treatment option for symptomatic atrial fibrillation (AF). Although published complication rates of CB2 based-PVI are relatively low and several safety algorithms have been implemented in the protocols the most frequent complication is right-sided phrenic nerve injury (PNI). The reported incidence of PNI varies from 2–5% of patients. However data on PNI characteristics as well as follow-up is sparse.

Purpose

We aimed to evaluate the incidence, characteristics and outcome of PNI during after CB2 based-PVI in a large patients population.

Methods and results

From July 2012 to November 2018 a total of 13693 patients received CB2 or CB3 (third-generation) based-PVI in 23 EP centers (Germany: 12, China: 1, Turkey: 3, Japan: 3, USA: 1, Austria: 1, Poland: 1, Swizerland: 1). A total of 596 (4.4%) of patients experienced PNI during treatment of the right superior (84%) right inferior (15%) right middle (0.3%) (and left superior (0.3%) pulmonary veins. The mean time to PNI was 127±51 seconds and the mean temperature at the time of PNI was −49±7 °C. The target PV was isolated at time of PNI in 84% of cases. The applications were interrupted using double-stop technique in (71%). In 212/306 (52%) a CMAP was utilized.

At the end of the procedure PNI persistent in 45% of patients. Fluoroscopic or sonographic evaluation of PNI was performed 1–3 days after the procedure and revealed persistent PNI in 35% of patients. Dyspnea before discharge was reported in 18% of patients with persistent PNI. Patients follow up at 1–3, and 6–12 months included fluoroscopy and a visit in an outpatient clinic. After 1–3 months 18% of patients showed persistent PNI including 13% of patients complaining of dyspnea. After 6–12 months of follow-up including fluoroscopic evaluation PNI was persistent in 1.8% of patients while dyspnea was reported by 1.7% patients. Only 0.08% of the overall population of 13693 patients showed permanent and symptomatic PNI.

Conclusion

The incidence of PNI during CB2-based PVI is low. About 55% of PNI recovered until the end of the procedure. Most of PNI recovered within 12 months. Symptomatic permanent PNI is very rare in patients after CB2/CB3-based PVI.

4964Loss-of-spen disturbs cardiac conduction in zebrafish mediated by impaired connexin43 function

Introduction

Genome-wide association studies identified SPLIT ENDS (SPEN) gene as an interesting candidate in the pathogenesis of heart failure. SPEN is known to be of importance in transcriptional regulation in several pathways and knockout in mice results in severe cardiac structural abnormalities and premature intrauterine lethality. Moreover, SPEN was associated with human 1.36 syndrome and is located in the critical region for congenital heart defects. Hence, spen seems to be of importance in cardiac physiology, but not much is known about its biologic function in the heart.

Purpose

The aim of our study was to further deepen the insights on spen's role in cardiac pathology.

Methods

Morpholino-mediated gene knockdown is an excellent method to approach in vivo function of cardiac candidate genes in zebrafish. We conducted spen-specific knockdown experiments and first analyzed the emerging heart failure and arrhythmia phenotype. Next, we assessed possible target genes of the transcriptional regulator spen by gene expression profiling and verified our results by quantitative real-time PCR (qPCR), Western Blot, in situ hybridization and further knockdown- and rescue-experiments.

Results

Spen-deficiency results in severe heart failure and arrhythmia in zebrafish. While in the first 24 hpf (hours post fertilization) spen-morphant embryos develop normally, they exhibit reduced contractility and bradycardia at 48 hpf. From 60 hpf onwards impaired spen function is associated with electrophysiological abnormalities, closely resembling human second grade av block as well as atrial and ventricular fibrillation. Transcriptional profiling of pooled spen-morphant hearts revealed connexin43 (cx43) to be severely downregulated. This finding was verified by qPCR, Western Blot analysis and in situ hybridization experiments. Consequently, we hypothesized cx43 to be transcriptionally controlled by spen and that inadequate function of spen lowers cx43 levels, thereby causing cardiac conduction abnormalities. Subsequently, we performed cx43-knockdown, which phenocopied the spen-morphants phenotype. Importantly, all loss-of function experiments could be rescued by overexpression of wild type cx43 mRNA. Moreover, sensitizing via double injection of sub-phenotypic concentrations of spen- and cx43-morpholinos resulted in a supra-additive effect, validating molecular crosstalk between spen and cx43 on the signaling level. Compared to unaffected controls, over 90% of sensitized embryos display the arrhythmia phenotype and show atrial- and ventricular fibrillation already at 48 hpf.

Conclusion

Our results demonstrate that the transcriptional regulator spen controls the transcription of connexin43 and that impairment of this mechanism leads to severe cardiac arrhythmia in zebrafish.

Streamlining drug discovery assays for cardiovascular disease using zebrafish

Introduction: In the last decade, our armamentarium of cardiovascular drug therapy has expanded significantly. Using innovative functional genomics strategies such as genome editing by CRISPR/Cas9 as well as high-throughput assays to identify bioactive small chemical compounds has significantly facilitated elaboration of the underlying pathomechanism in various cardiovascular diseases. However, despite scientific progress approvals for cardiovascular drugs has stagnated significantly compared to other fields of drug discovery and therapy during the past years.Areas covered: In this review, the authors discuss the aspects and pitfalls during the early phase of cardiovascular drug discovery and describe the advantages of zebrafish as an in vivo organism to model human cardiovascular diseases (CVD) as well as an in vivo platform for high-throughput chemical compound screening. They also highlight the emerging, promising techniques of automated read-out systems during high-throughput screening (HTS) for the evaluation of important cardiac functional parameters in zebrafish with the potential to streamline CVD drug discovery.Expert opinion: The successful identification of novel drugs to treat CVD is a major challenge in modern biomedical and clinical research. In this context, the definition of the etiologic fundamentals of human cardiovascular diseases is the prerequisite for an efficient and straightforward drug discovery.

Impact of atrial rhythm on pulmonary vein signals in cryoballoon ablation - Sinus rhythm predicts real-time observation of pulmonary vein isolation

Purpose

Real-time observation of pulmonary vein (PV) potentials with a spiral mapping catheter has emerged as a key electrogram-based procedural parameter to estimate lesion quality and titrate cryoenergy application during PV isolation (PVI) with the cryoballoon. Whether correct PV electrogram interpretation and thus PVI real-time observation rate depends on atrial rhythm during cryoballoon PVI is unknown. We compared observation rates of time-to PV isolation (TTI) during sinus rhythm (SR group) and during atrial fibrillation (AFib group) in cryoballoon PVI.

Methods

We prospectively included 157 consecutive patients undergoing cryoballoon PVI and compared the incidence of PVI real-time recording of each pulmonary vein during SR and in AFib.

Results

Overall PVI real-time observation rate was 82.1% (491/598 PV) with significantly higher TTI observation rate in the SR group (315/365 PV, 86.3%) compared to the AFib group (176/233 PV, 75.5%; p < 0.001). Per vein analysis demonstrated that only TTI observation rate in the left superior pulmonary vein (LSPV) was significantly higher during SR (85/92, 92.4%) compared to AFib (37/54, 68.5%; p < 0.001). Regression analysis revealed that atrial rhythm is a strong and independent predictor of PVI real-time observation in the LSPV with an odds ratio of 4.98 (95%-CI: 1.86–13.34, p = 0.001) to detect TTI during SR.

Conclusions

Our results demonstrate that correct interpretation of PV electrograms and thus PVI real-time observation is more likely in SR than in AFib. Hence, cardioversion of patients in AFib at the beginning of the procedure should be considered to yield higher PVI real-time observation rates facilitating TTI guided cryoenergy titration.

Therapeutic Chemical Screen Identifies Phosphatase Inhibitors to Reconstitute PKB Phosphorylation and Cardiac Contractility in ILK-Deficient Zebrafish

Patients with inherited dilated cardiomyopathy (DCM) often suffer from severe heart failure based on impaired cardiac contractility leading to increased morbidity and mortality. Integrin-linked kinase (ILK) as a part of the cardiac mechanical stretch sensor was found to be an essential genetic regulator of cardiac contractility. Integrin-linked kinase localizes to z-disks and costameres in vertebrate hearts and regulates the activity of the signaling molecule protein kinase B (PKB/Akt) by controlling its phosphorylation. Despite identification of several potential drug targets in the ILK signaling pathway, pharmacological treatment strategies to restore contractile function in ILK-dependent cardiomyopathies have not been established yet. In recent years, the zebrafish has emerged as a valuable experimental system to model human cardiomyopathies as well as a powerful tool for the straightforward high-throughput in vivo small compound screening of therapeutically active substances. Using the ILK deficient zebrafish heart failure mutant main squeeze (msq), which shows reduced PKB phosphorylation and thereby impaired cardiac contractile force, we identified here, in an automated small compound screen, the protein phosphatase inhibitors calyculin A and okadaic acid significantly restoring myocardial contractile function by reconstituting PKB phosphorylation in msq ILK-deficient zebrafish embryos.

Atrial Fibrillation Predicts Long-Term Outcome after Transcatheter Edge-to-Edge Mitral Valve Repair by MitraClip Implantation

Background: Atrial fibrillation is common in patients with mitral regurgitation (MR) and has a negative impact on the clinical outcome of patients with valvular heart disease. We aimed to evaluate the impact of pre-procedural atrial fibrillation on the long-term clinical outcomes of patients with MR undergoing transcatheter mitral valve repair by MitraClip implantation. Methods: We analysed 355 consecutive patients with and without atrial fibrillation with symptomatic, severe MR and inoperability or high surgical risk undergoing MitraClip implantation in a three-year follow-up. Results: In patients with pre-procedural atrial fibrillation undergoing MitraClip implantation, we found advanced age, higher baseline NT-pro-BNP levels, increased left atrial diameter, and higher rate of severe tricuspid regurgitation, compared to patients with sinus rhythm. In the three-year follow-up after MitraClip implantation, mortality and major adverse cardiovascular and cerebral events (MACCE) occur significantly more often in patients with atrial fibrillation, compared to patients without atrial fibrillation. Multivariate regression analysis confirmed atrial fibrillation (hazard ratio 2.39, 95%-confidence interval 1.06–5.41, p = 0.036) as an independent predictor for three-year-mortality after MitraClip implantation. Conclusions: Atrial fibrillation is an independent predictor for long-term mortality after MitraClip implantation. We demonstrate the association of atrial fibrillation with mortality and MACCE in the long-term follow-up of patients undergoing MitraClip implantation.

Mutation of the Na+/K+-ATPase Atp1a1a.1 causes QT interval prolongation and bradycardia in zebrafish

The genetic underpinnings that orchestrate the vertebrate heart rate are not fully understood yet, but of high clinical importance, since diseases of cardiac impulse formation and propagation are common and severe human arrhythmias. To identify novel regulators of the vertebrate heart rate, we deciphered the pathogenesis of the bradycardia in the homozygous zebrafish mutant hiphop (hip) and identified a missense-mutation (N851K) in Na⁺/K⁺-ATPase α1-subunit (atp1a1a.1). N851K affects zebrafish Na⁺/K⁺-ATPase ion transport capacity, as revealed by in vitro pump current measurements. Inhibition of the Na⁺/K⁺-ATPase in vivo indicates that hip rather acts as a hypomorph than being a null allele. Consequently, reduced Na⁺/K⁺-ATPase function leads to prolonged QT interval and refractoriness in the hip mutant heart, as shown by electrocardiogram and in vivo electrical stimulation experiments. We here demonstrate for the first time that Na⁺/K⁺-ATPase plays an essential role in heart rate regulation by prolonging myocardial repolarization.